|
OT WHIRLPOOL-EXTREMITY
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
HCPCS 97022
|
| Hospital Charge Code |
43000007
|
|
Hospital Revenue Code
|
431
|
| Min. Negotiated Rate |
$47.40 |
| Max. Negotiated Rate |
$151.68 |
| Rate for Payer: Aetna Commercial |
$121.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.24
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$131.14
|
| Rate for Payer: First Health Commercial |
$150.10
|
| Rate for Payer: Humana Commercial |
$134.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.04
|
| Rate for Payer: Ohio Health Group HMO |
$118.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.02
|
| Rate for Payer: PHCS Commercial |
$151.68
|
| Rate for Payer: United Healthcare All Payer |
$139.04
|
|
|
OT WHIRLPOOL-EXTREMITY
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
HCPCS 97022
|
| Hospital Charge Code |
43000007
|
|
Hospital Revenue Code
|
431
|
| Min. Negotiated Rate |
$47.40 |
| Max. Negotiated Rate |
$151.68 |
| Rate for Payer: Aetna Commercial |
$121.66
|
| Rate for Payer: Anthem Medicaid |
$54.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.24
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$131.14
|
| Rate for Payer: First Health Commercial |
$150.10
|
| Rate for Payer: Humana Commercial |
$134.30
|
| Rate for Payer: Humana KY Medicaid |
$54.34
|
| Rate for Payer: Kentucky WC Medicaid |
$54.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$55.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.04
|
| Rate for Payer: Ohio Health Group HMO |
$118.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.02
|
| Rate for Payer: PHCS Commercial |
$151.68
|
| Rate for Payer: United Healthcare All Payer |
$139.04
|
|
|
OUTSIDE PR AFT DEL CARE ONLY
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 59430
|
| Hospital Charge Code |
72000021
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$70.87 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$210.86
|
| Rate for Payer: Ambetter Exchange |
$170.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$92.05
|
| Rate for Payer: Anthem Medicaid |
$70.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$170.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$170.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$204.73
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$212.72
|
| Rate for Payer: Healthspan PPO |
$167.32
|
| Rate for Payer: Humana Medicaid |
$70.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$237.56
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$170.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.29
|
| Rate for Payer: Molina Healthcare Passport |
$70.87
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$221.79
|
| Rate for Payer: UHCCP Medicaid |
$96.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$170.61
|
|
|
OUTSIDE PR AFT DEL CARE ONLY
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
HCPCS 59430
|
| Hospital Charge Code |
72000021
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$327.25
|
| Rate for Payer: Anthem Medicaid |
$146.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$403.75
|
| Rate for Payer: Humana Commercial |
$361.25
|
| Rate for Payer: Humana KY Medicaid |
$146.16
|
| Rate for Payer: Kentucky WC Medicaid |
$147.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.00
|
| Rate for Payer: Ohio Health Group HMO |
$318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.25
|
| Rate for Payer: PHCS Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Payer |
$374.00
|
|
|
OUTSIDE PR AFT DEL CARE ONLY
|
Facility
|
IP
|
$425.00
|
|
|
Service Code
|
HCPCS 59430
|
| Hospital Charge Code |
72000021
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$327.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$403.75
|
| Rate for Payer: Humana Commercial |
$361.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.00
|
| Rate for Payer: Ohio Health Group HMO |
$318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.25
|
| Rate for Payer: PHCS Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Payer |
$374.00
|
|
|
OUTSIDE PR AFT DEL CARE ONLY(P
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 59430
|
| Hospital Charge Code |
720P0021
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$70.87 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$210.86
|
| Rate for Payer: Ambetter Exchange |
$170.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$92.05
|
| Rate for Payer: Anthem Medicaid |
$70.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$170.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$170.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$204.73
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$212.72
|
| Rate for Payer: Healthspan PPO |
$167.32
|
| Rate for Payer: Humana Medicaid |
$70.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$237.56
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$170.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$170.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.29
|
| Rate for Payer: Molina Healthcare Passport |
$70.87
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$221.79
|
| Rate for Payer: UHCCP Medicaid |
$96.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$170.61
|
|
|
OVAL RESURF PAT 32MM
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
OVAL RESURF PAT 32MM
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem Medicaid |
$1,074.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Humana KY Medicaid |
$1,074.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
OVAL RESURF PAT 35MM
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem Medicaid |
$1,074.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Humana KY Medicaid |
$1,074.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
OVAL RESURF PAT 35MM
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
OVAL RESURF PAT 38MM
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
OVAL RESURF PAT 38MM
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem Medicaid |
$1,074.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Humana KY Medicaid |
$1,074.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
OVAL RESURF PAT 41MM
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
OVAL RESURF PAT 41MM
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem Medicaid |
$1,074.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Humana KY Medicaid |
$1,074.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
OVA & PARASITES W/ID
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS 87177
|
| Hospital Charge Code |
30001316
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem Medicaid |
$8.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.90
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Humana KY Medicaid |
$8.90
|
| Rate for Payer: Humana Medicare Advantage |
$8.90
|
| Rate for Payer: Kentucky WC Medicaid |
$8.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
|
OVA & PARASITES W/ID
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS 87177
|
| Hospital Charge Code |
30001316
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.20 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.63
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
|
OVARIAN CYSTECTOMY
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 58925
|
| Hospital Charge Code |
76102262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$600.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
OVARIAN CYSTECTOMY
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 58925
|
| Hospital Charge Code |
76102262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$687.80 |
| Max. Negotiated Rate |
$6,385.65 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem Medicaid |
$687.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,561.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,385.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,157.59
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Humana KY Medicaid |
$687.80
|
| Rate for Payer: Humana Medicare Advantage |
$4,561.18
|
| Rate for Payer: Kentucky WC Medicaid |
$694.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,473.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$701.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
OVARIAN CYSTECTOMY
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 58925
|
| Hospital Charge Code |
76102262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$397.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$1,108.15
|
| Rate for Payer: Ambetter Exchange |
$729.22
|
| Rate for Payer: Anthem Medicaid |
$397.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$729.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$729.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$875.06
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,069.56
|
| Rate for Payer: Healthspan PPO |
$1,072.97
|
| Rate for Payer: Humana Medicaid |
$397.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$960.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$729.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$729.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$405.23
|
| Rate for Payer: Molina Healthcare Passport |
$397.28
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$947.99
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$401.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$729.22
|
|
|
OVARIAN CYSTECTOMY(P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 58925
|
| Hospital Charge Code |
761P2262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$397.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$1,108.15
|
| Rate for Payer: Ambetter Exchange |
$729.22
|
| Rate for Payer: Anthem Medicaid |
$397.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$729.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$729.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$875.06
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,069.56
|
| Rate for Payer: Healthspan PPO |
$1,072.97
|
| Rate for Payer: Humana Medicaid |
$397.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$960.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$729.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$729.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$405.23
|
| Rate for Payer: Molina Healthcare Passport |
$397.28
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$947.99
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$401.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$729.22
|
|
|
OVERNIGHT SP02 MONITORING
|
Facility
|
IP
|
$292.00
|
|
|
Service Code
|
HCPCS 94762
|
| Hospital Charge Code |
46000018
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$87.60 |
| Max. Negotiated Rate |
$280.32 |
| Rate for Payer: Aetna Commercial |
$224.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$227.76
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cigna Commercial |
$242.36
|
| Rate for Payer: First Health Commercial |
$277.40
|
| Rate for Payer: Humana Commercial |
$248.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.96
|
| Rate for Payer: Ohio Health Group HMO |
$219.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$254.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.48
|
| Rate for Payer: PHCS Commercial |
$280.32
|
| Rate for Payer: United Healthcare All Payer |
$256.96
|
|
|
OVERNIGHT SP02 MONITORING
|
Facility
|
OP
|
$292.00
|
|
|
Service Code
|
HCPCS 94762
|
| Hospital Charge Code |
46000018
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$100.42 |
| Max. Negotiated Rate |
$280.32 |
| Rate for Payer: Aetna Commercial |
$224.84
|
| Rate for Payer: Anthem Medicaid |
$100.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$227.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cash Price |
$146.00
|
| Rate for Payer: Cigna Commercial |
$242.36
|
| Rate for Payer: First Health Commercial |
$277.40
|
| Rate for Payer: Humana Commercial |
$248.20
|
| Rate for Payer: Humana KY Medicaid |
$100.42
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$101.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$102.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.96
|
| Rate for Payer: Ohio Health Group HMO |
$219.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$254.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.48
|
| Rate for Payer: PHCS Commercial |
$280.32
|
| Rate for Payer: United Healthcare All Payer |
$256.96
|
|
|
OXcarbazepine XR 150 MG Tablet
|
Facility
|
OP
|
$26.57
|
|
|
Service Code
|
NDC 17772012101
|
| Hospital Charge Code |
25004003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$25.51 |
| Rate for Payer: Aetna Commercial |
$20.46
|
| Rate for Payer: Anthem Medicaid |
$9.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.72
|
| Rate for Payer: Cash Price |
$13.29
|
| Rate for Payer: Cigna Commercial |
$22.05
|
| Rate for Payer: First Health Commercial |
$25.24
|
| Rate for Payer: Humana Commercial |
$22.58
|
| Rate for Payer: Humana KY Medicaid |
$9.14
|
| Rate for Payer: Kentucky WC Medicaid |
$9.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.38
|
| Rate for Payer: Ohio Health Group HMO |
$19.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.33
|
| Rate for Payer: PHCS Commercial |
$25.51
|
| Rate for Payer: United Healthcare All Payer |
$23.38
|
|
|
OXcarbazepine XR 150 MG Tablet
|
Facility
|
IP
|
$26.57
|
|
|
Service Code
|
NDC 17772012101
|
| Hospital Charge Code |
25004003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.97 |
| Max. Negotiated Rate |
$25.51 |
| Rate for Payer: Aetna Commercial |
$20.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.72
|
| Rate for Payer: Cash Price |
$13.29
|
| Rate for Payer: Cigna Commercial |
$22.05
|
| Rate for Payer: First Health Commercial |
$25.24
|
| Rate for Payer: Humana Commercial |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.38
|
| Rate for Payer: Ohio Health Group HMO |
$19.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.33
|
| Rate for Payer: PHCS Commercial |
$25.51
|
| Rate for Payer: United Healthcare All Payer |
$23.38
|
|
|
OXcarbazepine XR 300 MG Tablet
|
Facility
|
OP
|
$30.30
|
|
|
Service Code
|
NDC 17772012201
|
| Hospital Charge Code |
25004004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.09 |
| Max. Negotiated Rate |
$29.09 |
| Rate for Payer: Aetna Commercial |
$23.33
|
| Rate for Payer: Anthem Medicaid |
$10.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.63
|
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: Cigna Commercial |
$25.15
|
| Rate for Payer: First Health Commercial |
$28.79
|
| Rate for Payer: Humana Commercial |
$25.75
|
| Rate for Payer: Humana KY Medicaid |
$10.42
|
| Rate for Payer: Kentucky WC Medicaid |
$10.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.66
|
| Rate for Payer: Ohio Health Group HMO |
$22.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.91
|
| Rate for Payer: PHCS Commercial |
$29.09
|
| Rate for Payer: United Healthcare All Payer |
$26.66
|
|
